Prospective study of the relationship between musculoskeletal and psychological complaints and electromyographic activity during isometric muscular contractions in a working population

OBJECTIVES

This study focused on determining whether musculoskeletal and psychological complaints reported monthly over a 4-month period predicted muscular activity during and immediately after standardized worktasks and whether muscular activity during and immediately after these tasks predicted changes in complaint severity in the following 12 months.

METHODS

Surface electromyography (EMG) was recorded bilaterally from the upper trapezius, middle deltoid, and forearm extensor muscles of 45 postal workers (30 women) during sustained submaximal (25% of peak force) isometric contractions (wrist extension and shoulder abduction). Self-reported health complaints were recorded monthly. Musculoskeletal and psychological complaint-severity indices (MSI and PI, respectively) were computed from complaint-severity scores (intensity score x duration score). The history of complaints over the previous 4 months was included in adjusted regression models to predict muscular activity during and immediately after submaximal contractions. Muscular activity was included in adjusted models to predict changes in the complaint severity over the subsequent 12-month period.

RESULTS

A higher MSI predicted a lower EMG level in the trapezius muscle during submaximal contractions (P<0.014), whereas the PI did not predict the level of EMG in any of the muscles studied (P > 0.194). The EMG activity did not predict changes in the complaint severity over the subsequent 12 months.

CONCLUSIONS

These findings may support the hypotheses of pain adaptation or the dysfunction of synergistic muscular control in relation to musculoskeletal complaints. However, the findings did not indicate that increased or decreased muscular activity is a risk factor for heightened levels of complaints in the subsequent 12 months.

Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review

Skeletal muscle relaxants are a heterogeneous group of medications used to treat two different types of underlying conditions: spasticity from upper motor neuron syndromes and muscular pain or spasms from peripheral musculoskeletal conditions. Although widely used for these indications, there appear to be gaps in our understanding of the comparative efficacy and safety of different skeletal muscle relaxants. This systematic review summarizes and assesses the evidence for the comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions. Randomized trials (for comparative efficacy and adverse events) and observational studies (for adverse events only) that included oral medications classified as skeletal muscle relaxants by the FDA were sought using electronic databases, reference lists, and pharmaceutical company submissions. Searches were performed through January 2003. The validity of each included study was assessed using a data abstraction form and predefined criteria. An overall grade was allocated for the body of evidence for each key question. A total of 101 randomized trials were included in this review. No randomized trial was rated good quality, and there was little evidence of rigorous adverse event assessment in included trials or observational studies. There is fair evidence that baclofen, tizanidine, and dantrolene are effective compared to placebo in patients with spasticity (primarily multiple sclerosis). There is fair evidence that baclofen and tizanidine are roughly equivalent for efficacy in patients with spasticity, but insufficient evidence to determine the efficacy of dantrolene compared to baclofen or tizanidine. There is fair evidence that although the overall rate of adverse effects between tizanidine and baclofen is similar, tizanidine is associated with more dry mouth and baclofen with more weakness. There is fair evidence that cyclobenzaprine, carisoprodol, orphenadrine, and tizanidine are effective compared to placebo in patients with musculoskeletal conditions (primarily acute back or neck pain). Cyclobenzaprine has been evaluated in the most clinical trials and has consistently been found to be effective. There is very limited or inconsistent data regarding the effectiveness of metaxalone, methocarbamol, chlorzoxazone, baclofen, or dantrolene compared to placebo in patients with musculoskeletal conditions. There is insufficient evidence to determine the relative efficacy or safety of cyclobenzaprine, carisoprodol, orphenadrine, tizanidine, metaxalone, methocarbamol, and chlorzoxazone. Dantrolene, and to a lesser degree chlorzoxazone, have been associated with rare serious hepatotoxicity.

How to manage musculoskeletal conditions: when is ‘Rehabilitation’ appropriate?

Multidisciplinary rehabilitation has established efficacy in few musculoskeletal conditions. It is likely to be effective in the context of chronic back pain and possibly other types of chronic pain, and in frail older people with hip fractures. The principles of multidisciplinary rehabilitation, which include time-limited and goal-directed interventions, can be used in other musculoskeletal interventions but there have not yet been sufficient randomized trials to determine its effectiveness. Multidisciplinary rehabilitation is relatively costly and therefore is not likely to be cost effective unless it achieves return to work in people in the working-age group, or averts the need for residential care in frail older people.

Incidence of ulnar nerve entrapment at the elbow in repetitive work

OBJECTIVES

Despite the high frequency of work-related musculoskeletal disorders, the relation between work conditions and ulnar nerve entrapment at the elbow has not been the object of much research. In the present study, the predictive factors for such ulnar nerve entrapment were determined in a 3-year prospective survey of upper-limb work-related musculoskeletal disorders in repetitive work.

METHODS

In 1993-1994 and 3 years later, 598 workers whose jobs involved repetitive work underwent an examination by their occupational health physicians and completed a self-administered questionnaire. Predictive factors associated with the onset of ulnar nerve entrapment at the elbow were studied with bivariate and multivariate analyses.

RESULTS

The annual incidence was estimated at 0.8% per person-year, on the basis of 15 new cases during the 3-year period. Holding a tool in position was the only predictive biomechanical factor [odds ratio (OR) 4.1, 95% confidence interval (95% CI) 1.4-12.0]. Obesity increased the risk of ulnar nerve entrapment at the elbow (OR 4.3, 95% CI 1.2-16.2), as did the presence of medial epicondylitis, carpal tunnel syndrome, radial tunnel syndrome, and cervicobrachial neuralgia. The associations with "holding a tool in position" and obesity were unchanged when the presence of other diagnoses was taken into account.

CONCLUSIONS

Despite the limitations of the study, the results suggest that the incidence of ulnar nerve entrapment at the elbow is associated with one biomechanical risk factor (holding a tool in position, repetitively), overweight, and other upper-limb work-related musculoskeletal disorders, especially medial epicondylitis and other nerve entrapment disorders (cervicobrachial neuralgia and carpal and radial tunnel syndromes).

Diagnostic classification and orthopaedic physical therapy practice: what we can learn from medicine

Concepts of diagnosis and classification have a long history in medicine, while formal schemes of diagnostic classification in physical therapy are relatively new. Basic differences exist between medicine and physical therapy in the phenomena which are diagnosed and classified. However, similarities in the diagnostic and classification process provide an opportunity to learn from medicine as the process now evolves in physical therapy. This paper provides a brief history of the development of the concept of diagnostic classification in medicine and physical therapy. Difficulties associated with the process are described. Knowledge of these difficulties is used to analyze some of the evolving concepts of diagnostic classification in physical therapy, especially those related to orthopaedic physical therapy practice.

Calcification of the interclinoid and petroclinoid ligaments of sella turcica: a radiographic study of the prevalence

OBJECTIVES

The purpose of this study was to evaluate the prevalence of calcifications of the sella turcica, in particular, calcification of the interclinoid and petroclinoid ligaments (PCL).

DESIGN

Radiographic analysis of preoperative cephalometric film images.

SETTING AND SAMPLE POPULATION

Lateral cephlometric radiographs of 255 subjects presenting for orthodontic evaluation were reviewed. The number of subjects selected for this study was determined by power analysis.

EXPERIMENTAL VARIABLE

Two calibrated raters reviewed cephalometric projections and scored the films using a standardized rating scale.

OUTCOME MEASURE

The rating scale classified interclinoid ligaments (ICL) into one of four categories depending on the degree of calcification and PCLs as either, no calcification, partial or complete calcification.

RESULTS

Of all subjects, calcification of the ICL ranged from 39% rated as more than half calcified to 8% completely calcified. Petroclinoid analysis revealed 67% with no calcification, 23% with partial calcification and 9% completely calcified. Spearman's correlations were computed between age and the degree of calcification and between the degree of calcification for these two ligaments with a significant association between age and degree of calcification in the PCL, r = 0.185 (p = 0.003) and a significant association between the degree of calcification in the petroclinoid and ICLs, r = 0.186 (p = 0.003). In addition, chi-squared tests demonstrated statistically significant associations between the presence of calcification in the PCL to the distribution of age (p = 0.041) and between the presence of calcification in the ICL to the distribution of age (p = 0.045).

CONCLUSION

As calcification of these ligaments has suggestive associations with disease entities, their recognition as a variant of normal anatomy should be evaluated when assessing cephalometric radiographs.

What's ailing us? Prevalence and type of long-term disabilities among an insured cohort of orthodontists

Occupational health risks are present in every profession. This article reviews 4 commonly mentioned conditions that might be health risks in orthodontics and dentistry--musculoskeletal problems, carpal tunnel syndrome, dermatoses and allergies, and psychosocial problems--and compares the reported prevalence rates with data from the American Association of Orthodontists Long-Term Disability Insurance Plan. There is an estimated 3.56% prevalence of long-term disability among orthodontists. The expected and actual specific conditions affecting orthodontists could differ from those of the general public or of general dentists and do not appear to equate with self-reported surveys. Suggestions for improved reporting are made. Orthodontists appear to be quite healthy compared with other insured populations and the general public. Most long-term disabilities among orthodontists appear to be chronic illnesses and not repetitive injuries or specific occupational hazards.

[A medical-social description of and approaches to the prevention of musculoskeletal system diseases]

The epidemiological as well as medical-and-social aspects related with diseases of the musculoskeletal system as observed in the Saratov Region over the recent 7 years are presented in the paper. A set of measures was worked out to optimize the medical-and-social aid rendered to patients with defects in the musculoskeletal system; the mentioned measures can be also used to advance the prevention system.

Channelopathies in pediatric neurology

Although the genetic neurologic channelopathies are uncommon, they serve as models that further understanding of disease mechanisms in paroxysmal disorders. Many other neurologic channelopathies likely will be identified in the future.

Classification systems for upper-limb musculoskeletal disorders in workers:

OBJECTIVE

The purpose of this study was to provide a review of the available classification systems and to describe the similarities and differences in the structure of these systems.

METHODS

Classification systems of upper limb musculoskeletal disorders (MSDs) were located via electronic database searches and researchers' files. The classification systems were compared on the disorders they described and on the criteria presented for each disorder.

RESULTS

Twenty-seven classification systems were found after title, abstract, or full article review of 1671 articles. The systems differed in the disorders they included, the labels used to identify the disorders, and the criteria used to describe the disorders.

CONCLUSION

Twenty-seven classification systems were found that described disorders of the muscle, tendon, or nerve that may be caused or aggravated by work. No two systems were the same.

International monitoring of musculoskeletal complaints: A need for consensus

Musculoskeletal pain is the complaint most frequently reported in health interview surveys. There is a confusing magnitude of names given to musculoskeletal pain complaints reflecting diverging opinions and a lack of consensus of what it is all about. This article discusses how to monitor the occurrence of unspecified musculoskeletal complaints and possible sources of information are presented. The main focus of the article is on how to include musculoskeletal complaints in health interview surveys, and a standard question to be included in all general health questionnaires is recommended.

Preference-based measurement of health-related quality of life (HRQL) in children with chronic musculoskeletal disorders (MSKDs)

BACKGROUND

Health-related quality of life can be measured by patients' health preferences (utilities or values). No method for measuring health state preferences has been standardized for children with arthritis or other musculoskeletal disorders (MSKDs). Such a method is needed for economic evaluations of current and new pediatric treatments.

OBJECTIVES

1) To assess the feasibility of utility measurements in children with MSKDs, 2) to test the validity of the Health Utility Index (HUI) for these children, 3) to assess whether rating scale values can be mathematically converted into meaningful standard gamble (SG) utilities, and 4) to study whether parents can act as proxies for their children with respect to health state preferences.

METHODS

Eighty parents of children with MSKDs were consecutively sampled. Their children, if 8 years of age or older (n = 55), were studied concurrently. Utilities of current health states were obtained by using the SG and the HUI in random order. In addition, health state preferences were assessed using categorical and analog rating scales. Traditional nonutility measures of health status (the Childhood Health Assessment Questionnaire [CHAQ] and the Activities Scale for Kids [ASK]) were also completed. Intraclass correlation coefficients (ICCs) were calculated to assess concordance between the different utility measures and also between the ratings of the parents and their children.

RESULTS

Children 8 years of age or older were able to express the strength of their health state preferences using the HUI and rating scales. Children older than 10 years of age were able to use the SG method. The health state utilities of the parents were higher than those of their children. The utilities varied widely depending on the elicitation method. The expected high agreement between the SG and the HUI was not found (ICC = 0.028 for parents, ICC = 0.016 for patients). Unlike the SG, the global utilities derived from the HUI agreed better with preferences derived from rating scales (ICC = 0.23-0.25) and correlated with traditional health status measures (with CHAQ, r = -0.56; with ASK, r = 0.46) both for parents and children. It was not possible to mathematically convert rating scale preferences into SG utilities. The SG utilities were unrelated to results from the rating scales, the CHAQ, and the ASK. Especially for parents, the SG utilities were very high, even when ratings of the other measures indicated poor health.

CONCLUSIONS

Although it is possible to measure health utilities for children with MSKDs, the results are highly method dependent. The properties of the HUI in this population are more like those of the traditional health status measures rather than those of the SG. Preferences derived from rating scales, although easily performed, cannot readily be converted into SG utilities. Parents' ratings for their children are impaired by risk aversion.

Variation in the estimation of quality-adjusted life-years by different preference-based instruments

OBJECTIVES

To assess the interchangeability of preference-based health-related quality of life tools and compare the potential gains in quality-adjusted life years (QALYs) in patients with musculoskeletal disease.

METHODS

Consecutive patients visiting a rheumatology clinic completed health-related quality of life assessments at baseline and 3, 6, and 12 months with the EuroQol (EQ-5D), Health Utilities Index (HUI3), and Short-Form 6D (SF-6D). Patients rated their health changes retrospectively and responses were categorized into three groups: better, same, and worse. Correlations and repeated measures analysis of variance with post hoc contrasts and a Bonferroni correction were used to assess interchangeability of tools.

RESULTS

Results were based on 161 cases with complete baseline data and 98 cases with data at baseline and 12 months. Correlations ranged from 0.66 to 0.79. An interaction effect showed that for the better group, the EQ-5D showed a significantly greater mean improvement (0.15) than the HUI3 (0.07) or the SF-6D (0.05). For the worse group, the EQ-5D showed a significantly greater mean decrease (0.19) than either the HUI3 (0.05) or the SF-6D (0.03). QALYs differences between the better and worse groups were significantly greater (0.23) with the EQ-5D than with the HUI3 (0.11) or the SF-6D (0.09).

CONCLUSIONS

Although results moderately support the idea that the three tools are measuring a similar underlying construct, the tools are not interchangeable because they are scaled differently and produce varying results. These findings have potential implications for the interpretation and comparability of health outcome studies and economic analyses. Possible approaches are sensitivity analysis or standardization of scores before calculation of QALYs.

Rheumatologic manifestations of diabetes mellitus

Diabetes mellitus has been linked to disorders of bones and joints, including neuroarthropathy, limited joint mobility, and hyperostosis. Some of the relations have known pathogenic mechanisms, but most are based on epidemiologic findings. This article reviews the associations between diabetes mellitus and its putative rheumatologic manifestations, and proposes a classification composed of four categories: consequences of diabetic complications, consequences of metabolic derangements inherent to diabetes, syndromes that may share etiologic mechanisms with microvascular disease, and probable associations. This approach may facilitate a clearer understanding of the musculoskeletal conditions that are prevalent in patients with diabetes mellitus.

Early workplace intervention for employees with musculoskeletal-related absenteeism: a prospective controlled intervention study

Sickness absenteeism caused by musculoskeletal disorders (MSDs) is a persistent and costly occupational health challenge. In a prospective controlled trial, we compared the effects on sickness absenteeism of a more proactive role for insurance case managers as well as workplace ergonomic interventions with that of traditional case management. Patients with physician-diagnosed MSDs were randomized either to the intervention group or the reference group offered the traditional case management routines. Participants filled out a comprehensive questionnaire at the initiation of the study and after 6 months. In addition, administrative data were collected at 0.6, and 12 months after the initiation of the project. For the entire 12-month period, the total mean number of sick days for the intervention group was 144.9 (SEM 11.8) days/person as compared to 197.9 (14.0) days in the reference group (P < 0.01). Compared with the reference group, employees in the intervention group significantly more often received a complete rehabilitation investigation (84% versus 27%). The time for doing this was reduced by half (59.4 (5.2) days versus 126.8 (19.2), P < .01). The odds ratio for returning to work in the intervention group was 2.5 (95% confidence interval 1.2-5.1) as compared with the reference group. The direct cost savings were USD 1195 per case, yielding a direct benefit-to-cost ratio of 6.8. It is suggested that the management of MSDs should to a greater degree focus on early return to work and building on functional capacity and employee ability. Allowing the case managers a more active role as well as involving an ergonomist in workplace adaptation meetings might also be beneficial.

Making sense of highway construction: a taxonomic framework for ergonomic exposure assessment and intervention research

Construction is one of the most hazardous industries in the United States. Occupational health research to characterize the hazards in construction work has been hampered by the lack of a systematic approach to classification of construction work and its associated hazards. A taxonomy of construction work, a nested system of classification, has been developed to systematize the collection and reporting of exposure assessment data for the characterization and reduction of hazards and the prevention of musculoskeletal injury. This taxonomy subdivides construction work into the categories of stage, operation, task, and activity. It is based on a bidding specification system already in use within the industry and thus provides a terminology common among workers, supervisors, and managers. The identification of tasks and activities that are present in multiple stages and/or trades contributes to the efficiency of exposure data collection and facilitates the generalizability to other settings for both exposure data and intervention evaluations. The taxonomy provides a framework and vocabulary that facilitates field work and participatory research activities. It can also potentially be linked to personnel and economic data for estimation of costs of safety and health problems, as well as benefits of interventions. Although developed for construction ergonomics, the taxonomic approach has application to non-routine work in other industry sectors and possibly in occupational health research other than ergonomics.

Can we rely on retrospective pain assessments?

The objective of this paper was to study whether subjects in a workplace setting are able to assess the intensity of musculoskeletal pain retrospectively for a period of 3 months. The intensity of average pain and maximum pain in eight anatomic regions was assessed on a numeric rating scale. The results of 12 consecutive weekly pain recordings were compared with a final retrospective assessment of pain intensity covering the same 3-month period (119 subjects). The degree of agreement was good or excellent. The subjects were able to distinguish between the worst complaints and average complaints, and the subjective perception of aggravations or improvements corresponded to the direction of a change in score. Current complaint status slightly influenced the memory of pain. The reproducibility of the questionnaire was also assessed and showed kappa coefficients between 0.44 and 0.91 (36 subjects). The results suggest that subjects are able to accurately recall and rate the severity of pain or discomfort for a period of 3 months. These findings are of practical importance in epidemiologic studies, because they imply that retrospective reports on pain intensity are sufficiently reliable.

Determinants of the clinical course of musculoskeletal complaints in general practice: design of a cohort study

BACKGROUND

Musculoskeletal complaints are frequent and have large consequences for public health. Information about the prognosis after presentation in general practice is far from complete. Knowledge about determinants of the clinical course of musculoskeletal complaints is essential for management decisions and to inform patients about their prognosis. The purpose of this study is to provide information about the prognosis of musculoskeletal complaints other than low back pain by studying the course of these complaints in general practice and to identify determinants of this course.

METHODS

Patients of 18 years and older, who present in general practice with a new episode of a musculoskeletal complaint of the neck, shoulder, elbow, wrist, hand, arm, hip, knee, ankle or foot, are recruited by their general practitioner (GP). Participants will receive complaint-specific questionnaires by mail at baseline and after 3, 6, 12 and 18 months. The following putative determinants of the course of the complaints will be investigated: sociodemographic characteristics, characteristics of the complaint, psychosocial job characteristics, physical workload, physical activity during leisure time, pain coping, mood, kinesiophobia, social support, optimism. The primary outcomes are perceived recovery, pain, functional status, sick leave and overall quality of life.

The burden of musculoskeletal conditions at the start of the new millennium

Musculoskeletal conditions are extremely common and include more than 150 different diseases and syndromes, which are usually associated with pain and loss of function. In the developed world, where these conditions are already the most frequent cause of physical disability, ageing of the most populous demographic groups will further increase the burden these conditions impose. In the developing world, successful care of childhood and communicable diseases and an increase in road traffic accidents is shifting the burden to musculoskeletal and other noncommunicable conditions. To help better prepare nations for the increase in disability brought about by musculoskeletal conditions, a Scientific Group meeting was held to map out the burden of the most prominent musculoskeletal conditions at the start of the Bone and Joint Decade. In particular, the Group gathered data on the incidence and prevalence of rheumatoid arthritis, osteoarthritis, osteoporosis, major limb trauma and spinal disorders. Data were collected and organized by world region, gender and age groups to assist with the ongoing WHO Global Burden of Disease 2000 study. The Group also considered what is known about the severity and course of these conditions, along with their economic impact. The most relevant domains to assess and monitor the consequences of these conditions were identified and used to describe health states for the different stages of the conditions. Instruments that measure these most important domains for the different conditions were recommended. It is clear from data collated that the impact from musculoskeletal conditions and trauma varies among different parts of the world and is influenced by social structure, expectation and economics, and that it is most difficult to measure impact in less developed nations, where the predicted increase is greatest.

Musculoskeletal symptoms among farmers and non-farmers: a population-based study

Farming has been considered a high-risk occupation for musculoskeletal disorders. However, documentation of the increased risk is weak except for hip osteoarthritis. 1,013 full-time farmers in nine Swedish municipalities and 769 non-farmers (referents), matched for age, sex, and residential area, participated in the study. Information about medical history, consultations, and sick leave for musculoskeletal disorders was obtained by questionnaire and interview. The farmers reported significantly more symptoms affecting the hands and forearms, low back, and hips than did the non-farmers, and a non-significant trend in the same direction was found for symptoms from the neck, shoulders, and knees. However, the farmers did not seek medical advice more often than the referents, and they reported significantly less sick leave for these problems. Thus, farmers appear to have more musculoskeletal symptoms than do non-farmers.

Classification systems in orthopaedics

Classification systems help orthopaedic surgeons characterize a problem, suggest a potential prognosis, and offer guidance in determining the optimal treatment method for a particular condition. Classification systems also play a key role in the reporting of clinical and epidemiologic data, allowing uniform comparison and documentation of like conditions. A useful classification system is reliable and valid. Although the measurement of validity is often difficult and sometimes impractical, reliability-as summarized by intraobserver and interobserver reliability-is easy to measure and should serve as a minimum standard for validation. Reliability is measured by the kappa value, which distinguishes true agreement of various observations from agreement due to chance alone. Some commonly used classifications of musculoskeletal conditions have not proved to be reliable when critically evaluated.

Determining foot and ankle impairments by the AMA fifth edition guides

The fifth edition of the Guides has been criticized for its failure to provide a comprehensive, valid, reliable, unbiased, and evidenced-based system for rating impairments and the way in which workers' compensation systems use the ratings, resulting in inappropriate compensation [8]. The lower extremity chapter utilizes numerous functional and anatomic methods of assessment, as well as diagnosis-based estimates. Though this process of using multiple approaches to measure impairment increases the chances that an underlying physical impairment may be detected, it is time-consuming and may increase rating variability [9]. McCarthy et al studied the correlation between measures of impairment for patients with fractures of the lower extremity. They found that the anatomic approach of evaluation was better correlated than functional and diagnostic methods with measures of task performance based on direct observations as well as the patient's own assessment of activity limitation and disability. Also, muscle strength assessment as described in the Guides was a more sensitive measure of impairment than range of motion [9]. The most elusive part of the foot and ankle evaluation is the inability to capture the added impairment burden caused by pain. The assessment of pain is the most problematic part of any evaluation. Pain is considered and incorporated into the impairment ratings found in the foot and ankle section, as well as the other individual chapters. Chronic pain is often not adequately accounted for, however, and the examiner must evaluate permanent impairment from chronic pain separately. The examiner has the ability to increase the percentage of organ system impairment from 1% to 3% if there is pain-related impairment that increases the burden of illness slightly. If there is significant pain-related impairment, a formal pain assessment is performed. Chapter 18 provides guidance in making these determinations. Impairments for Complex Regional Pain syndrome (CRPS), type 1 (reflex sympathetic dystrophy), and CRPS, type 2 (causalgia) should incorporate the use of a formal pain assessment in addition to the standard methods of assessment. The formal pain evaluation relies mostly on self-reports from the individual and is most heavily weighted for ADL deficits. The physician must make assessments of the individual's pain behavior and credibility for this evaluation. The formal pain assessment classifies the pain-related impairment into categories of mild, moderate, moderately severe, or severe and determines whether this impairment is ratable or not. These categories do not have impairment percentages associated with them. The individual's symptoms or presentation should match known conditions or syndromes in order to be ratable. If not ratable, the examiner should report that the individual has apparent impairment that is not ratable on the basis of current medical knowledge. In the end, pain evaluations are used administratively and, depending on the situation, may be given equal weight with the standard evaluation or may be totally disregarded.

[DRGs of musculoskeletal diseases: consequences for orthopaedics and accident surgery]

The introduction of the new prospective payment system for inpatient care entails considerable changes for hospitals in Germany. The Australian Refined Diagnosis Related Groups (AR-DRGs), which form the basis for the German system, give the chance to estimate the consequences and implications for the specialty of orthopaedic surgery in Germany. Our study aims at highlighting the most important musculoskeletal diagnoses and to provide an initial economic forecast for them. The comparison with Australian data gives hints for operative and conservative-rehabilitative orthopaedic departments in respect to potentials and focal points for the development of novel patient management tools. The success of orthopaedic departments will depend in the future much more than now on organisational and management issues.

[Differential diagnosis of chronic pain syndromes of the musculoskeletal system--coding according to ICD-10]

Primary care for patients suffering from chronic pain is regularly provided by either family physicians or inpatient medical wards. A delay in initiating specific pain treatment is associated with poor outcome in terms of pain intensity, work disability and diminished quality of life. We present a diagnostic classification scheme for chronic pain disorders following the biopsychosocial disease model. This classification may help primary care providers initiate appropriate treatment early in the course of chronic pain, and aid in referral of their patients to services familiar with the treatment of chronic pain. Given increasing requests for quality control in health care and for transparency in disease management by health insurance companies, we propose a coding system of chronic non-malignant pain syndromes with the ICD-10.

Hip problems in older adults: classification by cluster analysis

No validated classification system of hip disorders in primary care is available. This study explores whether it is possible to obtain such a classification with the method of cluster analyses. A total of 224 consecutive patients aged 50 years or older, consulting the general practitioner for pain in the hip region, and referred for X-ray investigation of the hip, underwent a standardized examination. Ward's cluster analysis with variables from history and physical examination of the hip region resulted in a classification with nine different clusters. These clusters were reproduced in 10 random subsamples and with an alternative cluster analysis. Significant relationships of various external variables (radiological and sonographic signs and variables of low-back and knee examination) with the distinctive clusters were found. Twenty of the approached experts recognized the symptoms in seven clusters as identifiable syndromes. However, further validation of the achieved classification system, especially with respect to the clinical importance, is needed before introducing it into clinical practice.

Back and upper extremity disorders among enlisted U.S. Marines: burden and individual risk factors

Although musculoskeletal disorders of the low back and upper extremities can affect military readiness, little is known about their extent and risk factors in the U.S. Marine Corps. Using the Defense Medical Epidemiology and Defense Medical Surveillance System databases, back and upper extremity diagnostic categories were among the top four sources of outpatient visits and duty limitation among enlisted Marines. Back disorders were also found to be the fifth most common cause for lost time. Subsequently, high-risk occupations were identified, age-related trends for clinic visit rates were determined, and rate ratios were computed for the top 15 low back and upper extremity diagnoses among enlisted Marines from 1997 through 1998. Occupational categories with the highest rates of musculoskeletal-related outpatient visits included image interpretation, auditing and accounting, disturbsing, surveillance/target acquisition, and aircraft launch equipment. Significantly increasing linear trends in rates across age groups were found for most diagnoses. For 1998, age-specific rate ratios indicated significantly higher rates for most low back and upper extremity disorders for females; lower rank (i.e., E1-E4) was also a risk, but for fewer diagnoses. The findings emphasize the need to identify modifiable (e.g., work-related, individual) risk factors and to develop focused primary and secondary prevention programs for musculoskeletal disorders in the Marine Corps. Subsequently, these efforts can assist in reducing associated effects, maximizing resource utilization, and enhancing operational readiness.

Variation by diagnostic and practice pattern groups in the mobility outcomes of inpatient rehabilitation programs for children and youth

BACKGROUND AND PURPOSE

The purpose of this study was to describe variation in functional mobility outcomes among children and youth with different diagnoses and belonging to groups with different practice patterns from an inpatient pediatric rehabilitation hospital setting.

SUBJECTS

A sample of 138 individuals between the ages of 1 and 22 years (mean=9.4, SD=5.3) was enrolled.

METHODS

Physical therapists administered the "Mobility" domain of the Pediatric Evaluation of Disability Inventory at the time of admission and at the time of discharge. Mobility level (combined admission and discharge scores) and amount of change between and within 4 diagnostic groups (traumatic brain injury, non-traumatic brain injury, orthopedic, and neurological) and 5 neuromuscular and musculoskeletal practice pattern groups were calculated, and post hoc analyses were done for specific contrast comparisons.

RESULTS

Mobility scores between admission and discharge for all subgroups were different. Practice pattern groups were useful for identifying variations in level of motor performance. Diagnostic groups best described differences in mobility change during inpatient rehabilitation.

DISCUSSION AND CONCLUSION

The use of practice patterns as grouping categories may enhance our understanding of variation in clinical outcomes of children during inpatient rehabilitation.

[Comparison of principles for establishing disability pension eligibility for orthopedic cases used in Germany and in Poland. I. German rules for establishing eligibility in orthopedics]

The aim of the present paper is to compare the rules used in Germany and Poland to establish an individual's eligibility for a disability pension in cases of orthopedic disorders. Harmonizing these rules is one of the basic factors needed to create the proper platform for cooperation among health care systems in all the countries associated with the European Union. This first part of the work discusses the German rules for eligibility proceedings in orthopedic cases. The example of spinal disorders is used to explain the scheme of the examination conducted by the specialist to determine the disability group to which the person should belong. Attention is drawn to the rules governing the use of additional tests and eligibility proceedings.

[Comparison of principles used to establish eligibility for disability pensions for orthopedic cases in Germany and in Poland. II. Polish rules for establishing eligibility in orthopedics]

The goal of the present paper is to compare the rules used in Germany and Poland to establish an individual's eligibility for a disability pension in cases of orthopedic disorders. Harmonizing these rules is one of the basic factors needed to create the proper platform for cooperation among health care systems in all the countries associated with the European Union. This second part of the work will discuss the Polish rules for eligibility proceedings in orthopedic cases. The example of spinal disorders is used to explain the format for the examination conducted by an orthopedic specialist in the course of the process of determining the disability group to which the person belongs.

Musculoskeletal pain: prevalence, prevention, and differences among dental office personnel

Data regarding the presence and specific region of musculoskeletal pain were collected as part of a study that surveyed more than 5,000 dental personnel, dentists, and dental auxiliaries. The magnitude of the overall study, which included all types of dental professionals, made possible identification of the prevalence of musculoskeletal pain and comparison of regions of pain among the different dental professionals.

Severity of upper and lower extremity functional limitation: scale development and validation with self-report and performance-based measures of physical function. WHAS Research Group. Women's Health and Aging Study

OBJECTIVES

To better understand disablement and transitions from impairment to disability, discrete valid measures of functional limitation are needed. This study reports the development and criterion-related validity of scales that quantify severity of upper and lower extremity functional limitation.

METHODS

Data are from 3,635 cognitively intact community-dwelling women aged 65 years and older and 1,002 moderately to severely disabled participants in the Women's Health and Aging Study. Scales assessing severity of upper and lower extremity functional limitation were constructed from commonly available questions on functional difficulty. Criterion-related validity was evaluated with self-report and performance-based measures.

RESULTS

The upper and lower extremity scales range from 0 to 6 and 0 to 9, respectively. Scale scores were well distributed in the disabled group and discriminated limitations in the broader community. For both scales, rates of difficulty for all ADL and IADL increased (p<.001) with increasing severity score, and percent able and mean performance on respective upper and lower extremity tasks decreased (p<.01).

DISCUSSION

These scales, constructed from commonly used self-report measures of function, provide discrete measures of upper and lower functional limitation. Because these scales are distinct from measures of disability and impairment, their use should facilitate increased understanding of the disablement process.

A new symmetry-based scoring method for posture assessment: evaluation of the effect of insoles with mineral derivatives

BACKGROUND

There is a need for a validated rapid procedure for the evaluation of posture, defined as lateral balance/imbalance at the pelvic, shoulder, and neck levels. This would enable clinicians to determine the importance of symmetry in the pathophysiology of musculoskeletal disorders and to assess the efficacy of devices and treatments claiming to normalize or improve posture. In this investigation, the efficacy of such a device, a set of insoles with a hypothesized proprioceptive-like action, was evaluated through use of the described procedure.

OBJECTIVES

To develop a new scoring system to evaluate body posture on the basis of symmetry and to use this scoring system to investigate the efficacy of insoles containing a combination of mineral derivatives designed to balance posture through a neurophysiological effect.

METHODS

The posture score was based on the evaluation of 4 postural parameters: pelvic and shoulder lateral balance/imbalance, static shoulder rotation, and amplitude of head rotation. In the placebo-controlled study, 32 patients were tested in a double-blind fashion, either with placebo insoles or with insoles containing mineral derivatives. The same study was repeated in unblind conditions in 137 patients selected from 2 chiropractic clinics in an open-label protocol.

STUDY DESIGNS

A crossover placebo-controlled, double-blind study and a multicenter, large-scale, open-label study in patients selected from chiropractic clinics.

RESULTS

A basal postural evaluation in 137 patients revealed that no patient had a perfect symmetry-ie, a perfectly or nearly perfectly balanced posture. The insoles with mineral derivatives induced a highly significant and similar improvement in the postural score in both the crossover double-blind study (32 patients; 56.7% improvement) and the open-label study (137 patients; 60.7% improvement, P < 0.001).

CONCLUSIONS

All patients tested and selected in chiropractic clinics exhibited asymmetries and postural imbalances according to the newly developed scoring method, and this method was successful in assessing the efficacy of insoles exerting a profound and immediate postural effect through a hypothesized neurophysiological mode of action.

Classification criteria and severity assessment in work-associated upper extremity disorders: methods matter

Work-associated musculoskeletal disorders of the upper extremity are common and disabling. Research on these disorders is needed and requires valid methods of classification of the disorders for epidemiologic studies and measurement of their impact on functional status. This commentary discusses the methodologic aspects of classification and functional status assessment in upper extremity musculoskeletal disorders.

[Diseases with relevance to protection of animals with an example of the musculoskeletal system of dogs]

Protection of animals needs major concern in breeding programmes especially if inherited diseases occur which cause pain, suffering and/or damages for the animals. Dogs breeders and people keeping dogs as well as veterinarians should be informed about the etiology on sequels of diseases which cause pain to the animals and from which the animals have to be protected in order to make them more conscious on these problems and to achieve changes in dog breeding programmes. The information system "Inherited Diseases of the Musculoskeletal System of Dogs" should display the already published knowledge about etiology, pathogenesis, appearance, therapy and genetics of these diseases. This information system was built up in such a way that it can be used by students as a learning programme to understand the basic relationships among animal protection, diseases, and dog breeding. The user is also supplied with support for breeding decisions as well as for interpretation of breeding values and genotype probabilities. Additionally, information can be obtained on all in the German Association for Dog Breeding (VDH) represented breeds and breeding clubs. Actions to reduce genetically caused diseases required for members of dog breeding clubs are also available. The information system ist programmed by using HTML (Hyper Text Markup Language). Publication is possible on CD-ROM and on Internet. The supplied hyperlinks allow to make use of other publications on the world wide web related to dog and diseases of dogs.

Retrospective versus original information on physical and psychosocial exposure at work

OBJECTIVES

Retrospective exposure assessments are often performed in epidemiologic studies. The presence of an eventual misclassification, both nondifferential and differential, is debated but can rarely be investigated. The aim of this study was to compare self-reported information on the same physical and psychosocial work exposures with 25 years' difference.

METHODS

In 1969-1970 a survey of randomly chosen men and women in Stockholm county, concerning, among other things, work exposures, was undertaken. During 1993-1994, 280 subjects participated in a reexamination, regarding psychosocial and physical factors at work and musculoskeletal disorders. The questions were all formulated in the same way as in 1969-1970.

RESULTS

When self-reported information on work exposures, collected with a 25-year interval, was compared, acceptable, although not high, agreement was found for 3 out of 4 physical factors and for 4 out of 10 physical environmental factors. Questions measuring psychosocial load had somewhat lower agreement. Current exposure status influenced the memory of past exposures. Study subjects who reported low-back disorders at the reexamination tended to show a better agreement in their assessments of retrospective exposures than those without current symptoms. When relative risks from original and retrospective data were calculated, hardly any influence on the estimates due to that differential misclassification could be found. For persons with and without neck or shoulder symptoms no apparent differences in assessments were found.

CONCLUSIONS

Retrospective assessments of exposures at the workplace showed misclassifications to a certain degree. However, the influence of the misclassifications on the risk estimates was limited.

Summary of ICD-9-CM Coordination and Maintenance Committee meeting

The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Health Care Financing Administration (HCFA), recently met in Baltimore, MD. Donna Pickett, RRA (NCHS), and Patricia Brooks, RRA (HCFA), cochaired the meeting. Proposed modifications to ICD-9-CM were presented and are summarized below. Unless otherwise indicated, the audience generally supported the proposed changes.

Smoking and musculoskeletal disorders in the metal industry: a prospective study

OBJECTIVES

To obtain longitudinal information of the relation between smoking and musculoskeletal disorders in an industrial setting.

METHODS

The associations of lifetime tobacco exposure (pack-years), current smoking status, and stopping smoking with back and limb disorders were studied in a cohort of white collar and blue collar employees in a metal industry. Measurements were made three times at 5 year intervals. Two thirds of an initial sample of 902 took part in both re-examinations. Musculoskeletal morbidity was measured as the abundance of symptoms during the past year and as clinical findings assessed by a physiotherapist (upper decile score/score difference = index category). Logistic regression and a generalised estimating equation were used, allowing for sociodemographic variables, physical workload, body mass index, exercise activity, and mental distress.

RESULTS

By comparison with never smokers, exposure of 10-< 20 pack-years, the odds ratio (OR) (95% confidence interval (95% CI) of the 10 year change in neck-shoulder symptoms was 3.1 (1.4 to 6.8), in low back symptoms 2.4 (1.1 to 5.1), in upper limb symptoms 1.9 (NS), and in lower limb symptoms 3.4 (1.5 to 7.8). The highest exposure category of > or = 20 pack-years was associated with the change in upper limb findings 2.9 (1.4 to 6.2) and lower limb findings 2.9 (1.2 to 7.2). Those who continued to smoke through the follow up period had a higher increase in clinical findings 2.5 (1.1 to 5.9) than never smokers. There was a dose-response in the association of smoking intensity with future musculoskeletal symptoms. Also, those who stopped smoking during the follow up had a higher increase in symptoms 4.4 (2.0 to 9.9) and findings 3.5 (1.4 to 8.8) than never smokers.

CONCLUSION

Smoking seems to predict the development in the occurrence of musculoskeletal symptoms and signs. Stopping smoking is associated with high morbidity.

New payments and incentives in contact capitation: an orthopedics case study

The purpose of this article is to present a model for equitable distribution of orthopedic contact capitation payments. This model accounts for services covered, patient severity of illness, patient age, and condition prevalence.

Length of disability and cost of work-related musculoskeletal disorders of the upper extremity

There is little information on the length of disability (LOD) reported for work-related musculoskeletal disorders of the upper extremity (WMSDUE). For this study, LOD, cost, and the relationship between LOD and cost were derived from a large workers' compensation company's claims data for 1994 WMSDUE (n = 21,338). The average LOD was 87 days, with a median of zero days. For those claims with at least one day of compensable disability (25.2%), the average and median LOD were 294 and 99 days, respectively. The distribution of cost was skewed, with the average cost of a claim being 13 times higher than its median. Approximately 60% of the claims cost $1000 or less. Additionally, the 6.8% of the claims with an LOD greater than one year accounted for 59.9% of the cost and 75% of the total disability days. The majority of WMSDUE claimants did not lose sufficient time to qualify for indemnity. For those who did receive lost time wages, a disability duration of more than three months was typical.

Demand-based assessment of workforce requirements for orthopaedic services

On the basis of an analysis of the supply of and demand for orthopaedic surgeons, we projected that there will be 21,134 full-time-equivalent orthopaedists in the year 2010 if training continues at current levels. We estimated a demand-based requirement of 17,012 full-time-equivalent orthopaedic surgeons, indicating a surplus of 4122 full-time equivalents. In terms of orthopaedist-to-population ratios, we estimated that there will be 7.5 full-time-equivalent orthopaedists per 100,000 population in 2010 compared with a demand-based requirement of 6.0 full-time equivalents. However, we did not include estimates of the demand for orthopaedic surgeons as assistants in the operating room in our model. If an assistant orthopaedic surgeon is required for all procedures, an additional 3906 full-time-equivalent orthopaedists would be demanded, thus eliminating the surplus. The demand for an assistant orthopaedic surgeon in only half of the procedures would still lead to a sizable reduction in the surplus.

Making sense of musculoskeletal disorders

Evaluating musculoskeletal disorders can be challenging and time-consuming. Grouping the information from the history and physical examination into broad categories, inflammatory vs. non-inflammatory and local vs. systemic, serves as a general approach.

Assessing health in musculoskeletal disorders--the appropriateness of a German version of the Sickness Impact Profile

The Sickness Impact Profile (SIP) is gaining increasing popularity in clinical and epidemiological studies, assessing health status or the impact of therapeutic interventions. The SIP was created as a global measure, assessing generic dimensions of health. As there were only a few such methods available in our country, we decided in 1990 to validate a German version of the SIP and to test its appropriateness in patients with musculoskeletal disorders. Due to the up-to-dateness of our results, we decided to publish now the data of this German version of the SIP. Reliability, validity and sensitivity to change of the German version of the SIP were tested in 299 patients with musculoskeletal disorders. The test-retest correlation was high for the overall score (r = 0.81), as well as for Cronbach's alpha (r = 0.83). Results for categories were significantly lower. Validity was tested by comparing the SIP to the Keitel Index (r = 0.6) and to the Measurement of Patient Outcome Scale (r = 0.72), as well as to a control group, which showed significant differences in all categories and in the overall score. Furthermore, the SIP was able to demonstrate therapy-related improvements in health in all our patients. We concluded that the german version of the SIP fulfilled statistical test criteria. The results were comparable to those achieved in the original American version. A cross-cultural comparison using the SIP is justified for at least those patients with musculoskeletal disorders.

[Simple and valid ICD9-/10- and IKPM coding using an electronic data-assisted coding system "do it"--experiences after one years use]

Question by introducing "Fallpauschalen" and "Sonderentgelte" in German health system the coding of diagnoses and therapies gains a new momentum. Therefore, a new computer based coding-system for ICD- and ICPM- digits is presented. The physician gets enabled for simple and valid classification within his documentation routine.

METHODS

Development of a hierarchic menue system, whose first part represents the anatomic region. The second part is reserved for the most common diagnosis rsp. therapies within its special anatomic region. By further sub-menues all other ICD numbers in the orthopedic and traumatologic field may be coded (selection related by frequency). This coding-system has been in clinical use since jan. 1st. 1995.

RESULTS

Control of the efficiency of this coding-systems by 1316 patients with 1551 operations within one year. By using ICD-10, the representation of orthopedic-traumatologic diagnosis inhanced by factor 1.8 versus ICD-9. According to ICPM, 3560 therapies were coded, making it 2-3 actions per operation. "Fallpauschalen" were found in 21.9%, in 27.7% there were "Sonderentgelte". Within one year the coding error rate was reduced from 25% to 5%.

CONCLUSIONS

Because of its easy handling the coding system "do it" represents a good alternative to conventional coding rsp. clear text analysis.

[Patient-centered evaluation of illness outcome in musculoskeletal diseases: model of illness sequelae and definition of the concept]

Musculoskeletal conditions usually cause pain, physical, psychological and social disability, and consequently reduce a patient's quality of life. Nowadays, it is generally accepted that patients are truly capable to assess disease consequences, if they are questioned with appropriate instruments. Models of disease and the disabling process provide the conceptual background for the measurement of disease consequences. To date, standardized assessment of outcomes with psychometrically sound instruments is commonplace in clinical trials, clinical epidemiology, economic studies, and health services research. However, standardized assessment tools are not yet widely used in clinical practice.

[Patient-centered evaluation of illness outcome in musculoskeletal diseases: selection and testing of outcome instruments]

Effectiveness research, economic evaluation, epidemiologic studies of disease consequences and clinical quality management all rely on standardized assessment of disease consequences with psychometrically sound questionnaires. For scientific, ethical and economical reasons, careful selection and evaluation of instruments is critical. Selection of instruments includes searches of medical databases (e.g. MEDLINE), testing of face-validity (does the instrument measure what we intend to measure?), and compatibility (is the instrument used internationally?). Evaluation of instruments includes the assessment of reliability, internal consistency and sensitivity. Most important is careful consideration of the practical usefulness (Interpretation of scores and scales, acceptance in the study population). Contact with instrument developers is advisable (Copyright issues, scoring, current version).

Biopsychosocial features of patients with widespread chronic musculoskeletal pain in family medicine clinics

OBJECTIVES

We aimed to describe the clinical and psycho-socio-familial features of patients with widespread chronic musculoskeletal pain (WCMP)/fibromyalgia (FM) in primary care settings. To detect differences and similarities between both 'entities'.

METHODS

An observational study was carried out with a newcoming clinical case series. Five family medicine surgeries were included. Patients aged from 18 to 50 attended the clinic to fulfil pain criteria for WCMP. Differences between WCMP and FM were based on the presence of 'tender points'. Measurements were made of general characteristics, occupation, pain description, symptoms, tender points, radiographic and laboratory studies, and questionnaires to assess self-rated health (NHP), social support (DUKE), family support (Family-APGAR), and psychopathological traits (CAQ).

RESULTS

We identified 48 patients (23 WCMP;25 FM) with a mean age of 38.4 +/- 8.4; 95.8% were females. The back was the anatomical place most frequently reported (93.7%) and 34.8% of the patients pointed out the nape as being the most painful place. The average duration of pain was 6.7 +/- 7 years. Unsteadiness (72.9%), impairment in symptoms with weather (70.8%), with activity (70.8%) and general fatigue (68.8%) were the most frequently detected symptoms. 'Pain' (59.5) and 'energy' (54.4) were the scales of the NHP test most affected. Half of the patients were poorly satisfied with the responses of their families to their needs and over 60% showed psychopathological traits. The patients with FM reported worse self-rated health than those with WCMP; the number of years of pain (4.9 versus 8.2) and the number of symptoms (6.6 versus 8.9) were both greater in patients with FM.

CONCLUSIONS

The clinical and psychological features of patients with WCMP-FM are similar to those reported by others. The self-rated health reported by these patients is poor and closer to that reported by patients suffering other chronic osteoarticular diseases. These results support the hypothesis that FM should be considered as more advanced clinical stage of the widespread musculoskeletal pain continuum.